MONITORING CHARTS FOR ROUTINE EPI

MONITORING CHARTS FOR ROUTINE EXPANDED PROGRAMME ON IMMUNISATION (EPI)

MONITORING CHARTS FOR ROUTINE EPI AT THE HEALTH AREA AND HEALTH DISTRICT LEVELS

22 December 2011

Dr Mfonfu Daniel Ngongho

Independent Researcher

Email address: dmfonfu@yahoo.com

Tel:(+237) 677601207

INTRODUCTION
Health care providers at the level of the Health Areas and Health Districts are confronted with a multitude of EPI monitoring charts of different formats from a variety of sources; usually these charts are similar to the one-oblique line chart recommended by the World Health Organisation (WHO).

‘Monitoring refers to reviewing, on continuous basis, the degree to which program activities are completed, targets are being met. This allows corrective action to be taken during program implementation’ (MSH&WHO Management of Drug Supply)

Monitoring is keeping track of ongoing operational activities, milestones or objectives attainment, the use of budget, staff time and other resources. It facilitates reprogramming of strategy, and eventual evaluation (MLM). Monitoring should be carried out at all levels using appropriate charts that enhance the easy visual appreciation of trends of indicators in relation to set objectives especially in routine EPI.

I have worked in the immunisation programme in Cameroon for several years from 1982 to 2006. I produced the monitoring charts in the initial version of the Norms and Standards for Routine Expanded Programme Immunisation for Cameroon in 2002, including the multiple-oblique line chart. Over the years based on the appreciation of my curriculum vitae, my competence, my capacity for initiating improvement of health programmes, I was recruited as:

• WHO consultant to support Tchad in the organisation of National Immunisation Days against Polio and to strengthen the Routine Expanded Programme of Immunisation (EPI) from 13 May – 01 July 2000, and from 07 October 2000 – 31 May 2001, at the Delegation of Health of Moyen Chari.
• Trainer on Infection Prevention and on syndromic management of sexually transmitted infections at Tendaba in Gambia by SFPS, USA from 21 to 29 March 2003.
• Trainer on internal supervision at Tendaba in Gambia by SFPS, USA from Tuesday 1 April 2003 to Friday 4 April 2003.
• A STOP team member as WHO/CDC Consultant to carry out facilitative supervision and provide support in strengthening activities of active surveillance for Acute Flaccid Paralysis, measles and neonatal tetanus and the Expanded Program on Immunization (EPI) in Madagascar from 24 May – 12 August 2006 (with Orientation at CDC Atlanta 10 – 19 May 2006).
• A UNV to UNHCR Lubumbashi, as public health coordinator from 22 July 2009 to 30 May 2011; where I had to ensure that health care to internal displaced persons, the refugees, and the repatriated is of national and international norms.

A consultant should be able to make a special, acceptable and scientific input during his consultancy instead of just following an established routine process of doing things that may not be correct or appropriate. This is what I tried to do during my consultancies especially concerning the strengthening of EPI.

In Tchad in the Delegation of Health of Moyen Chari in 2000 I introduced the multiple-oblique line chart for the monitoring of output indicators of routine EPI - vaccination coverage rates and set objectives. The vaccination coverage rate expressed in percentage for each EPI antigen at the end of each month is the cumulative vaccinated number of target population since January of the year divided by the corresponding cumulative target population of the same month since January multiplied by 100.

The drop out rate expressed also in percentage is used for multiple vaccines. It is calculated at the end of each month thus, as example: (Cumulative vaccinated number of 0-11m having received DPT1 at the end of the month - Cumulative vaccinated number of 0-11m having received DPT3 for the same month) divided by Cumulative vaccinated number of 0-11m having received DPT1 of the same month multiplied by 100.

The multiple oblique-line chart for the monitoring of output indicators of routine EPI was included in my report produced in Tchad in 2000 and it was being by the WHO.

As a member of the STOP team to Madagascar in 2006 I observed the use of this one-oblique line chart recommended by the WHO and recorded the difficulty in filling it and its interpretation. I gave my impression about it to WHO and CDC, and published in my web site, www.mfonfudaniel.blogspot.com, as ‘Monitoring charts for routine expanded programme on immunisation (EPI), August 2006,’ introducing the multiple-oblique line chart to no avail.

In RDC at Lubumbashi in 2011 I initiated a reflection on the monitoring charts for vaccination coverage rate in routine EPI introducing the multiple-oblique line chart at the Health Area and Health District levels.

I am committed to persuading the stakeholders and countries to adopt this multiple-oblique line monitoring chart because it is scientifically correct and staff friendly; I introduced to WHO in 2000 during my consultancy for WHO in Tchad.

GOAL
Propose the multiple-oblique line monitoring chart and the horizontal line chart for the monitoring of vaccination coverage rates using cumulative data in routine EPI.

SPECIFIC OBJECTIVES

I. Study the WHO recommended EPI monitoring chart

II. Study some monitoring charts used by health staff.

III. Present and describe the proposed monitoring graphs

METHOD

Monitoring charts recommended by WHO for routine EPI, charts found in some reference documents, charts used in the countries I visited, and charts in Bamenda Health District are reviewed and their data extracted and used to produce the multiple-oblique line charts and the horizontal line charts to explain this contribution to data analysis and information management for decision making in Routine EPI at the level of Health Area and the Health District.

The charts studied are:

- The routine EPI monitoring chart recommended by the WHO (Picture 1)

- Cumulative Coverage and drop out monitoring chart, in Immunization Essentials, A practical field guide (Picture 2, Picture 3, Picture 4)

- Monthly monitoring of vaccination coverage rate in Huambo Province in 2004 in Angola (Picture 5, Picture 6, Picture 7).

- Chart for the monitoring of vaccination coverage rate in Madagascar (Picture 8, Picture 9, Picture 10, Picture 11)

- Review of monitoring charts in the Katanga Province in the Democratic Republic of Congo (Picture 12).

- Bamenda (Cameroon) Health District monitoring graphs (Picture 13, Picture 14, Picture 15).

- Proposed EPI monitoring charts for Health Area and Health District. (Picture 16, Picture 17)

· The routine EPI monitoring chart recommended by the WHO

The WHO recommended Immunisation monitoring chart for DTP1and DTP3 is a rectangular one-oblique line chart (Picture 1). It has 12 columns each subdivided into 2 columns thus having a total of 24 columns. It has 13 rows with the role of the 1st and 13th rows not well defined. It has an oblique line running from 0 at the principal y-axis to the 13th row at the secondary y-axis at 100%, which serves as a fixed objective. The graph drawn on it is always ascending giving the false impression that the vaccination coverage rate is always good and increasing. This chart cannot be produced with the chart wizard of the computer. The formula for the calculation of the drop out rate is not specific for cumulative data; it should be (Cumulative vaccinated number of 0-11m having received DPT1 in the month - Cumulative vaccinated number of 0-11m having received DPT3 in the same month) divided by Cumulative vaccinated number of 0-11m having received DPT1 in the same month multiplied by 100.

· Cumulative Coverage and drop out monitoring chart, in Immunization Essentials, A practical field guide

It is similar to the recommended World Health Organisation (WHO) chart except that its cumulative percentage is placed on the principal y-axis, while the cumulative target population is on the secondary y-axis (Picture 2). It contains 13 rows with the first row serving as zero. It has two columns for each month except for January, one for children vaccinated in the month and the other for total (cumulative number vaccinated since January). The formula for calculating the drop out rate is not specific for the use of cumulative data. The chart cannot be produced by computer in the present format. Using the data on the chart the author has produced a multiple-oblique line graph with the computer that shows obliquely the vaccination coverage rate as would be calculated from monthly cumulative data (Picture 3). The objective can be set by bolding one of oblique lines; the vaccination coverage rate is read between two oblique lines. The cumulative vaccination coverage rate in Sitapur is between 50% and 60% at the end of September. A horizontal line chart has been developed with the computer that shows monthly evolution of vaccination coverage rate in horizontal lines calculated from cumulative data (Picture 4). The cumulative vaccination coverage rate in Sitapur is 55.6% for DPT1 and 38.5% for DPT3 at the end of September

· Monthly monitoring of vaccination coverage rate in Huambo Province in 2004 in Angola.

The chart is similar to the WHO one-oblique line chart (Picture 5). There is only one column per month, offering a possibility to produce it with the computer. The chart is a rectangle. The proportion of the annual target population vaccinated is calculated (Total monthly cumulative vaccinated divided by the total annual target population x 100%) instead of the vaccination coverage rate using the corresponding cumulative data (Total monthly cumulative vaccinated divided by the corresponding monthly cumulative target population x 100%). The drop out rate is calculated based on the monthly data (Target population vaccinated in the month for DTP1- Target population vaccinated in the month for DTP3)/ Target population vaccinated in the month for DTP1; instead of (Cumulative target population vaccinated in the month for DTP1- cumulative target population vaccinated in the same month for DTP3)/ Cumulative target population vaccinated in the month for DTP1. A multiple-oblique chart has been drawn by the author using data extracted its original chart (Picture 6). It shows a sudden rise of the curves in February; and at the end of August vaccination coverage rates are above 100%. The horizontal line chart shows that the vaccination coverage rates in Huambo Province is 161.6% for DPT1 and 122.2% for DPT3 (Picture 7) at the end of August. The monthly drop out rate at the end August is 21.7% while the correct cumulative drop out rate at the end of the same month is 24.4%.

· Monitoring Chart for DTCHepB1 and DTCHepB3 of Service de SSPFD de BEROROHA in Madagascar

The monitoring chart is similar to the WHO monitoring chart except that it has twenty rows (Picture 8). The plotting of data and interpretation of this chart by health staff is extremely difficult; they have to resort to alternative graphs to appreciate the vaccination coverage rates (Picture 9). The multiple-oblique line chart shows that the trends of the vaccination coverage the end of May is above 100% for DTCHepB1 and between 90% and 80% for DTCHepB3 (Picture 10). The horizontal line chart drawn with data extracted from the twenty rows chart shows a vaccination coverage rate of 137.6% for DTCHepB1 and 87.2% for DTCHepB3 at the end of May 2006 in Beroroha (Picture 11).

· Monitoring Chart for routine EPI in RDC in the Katanga Province

The monitoring charts are the recommended WHO monitoring charts, with six of them put in one big sheet (Picture 12). The plotting of data and interpretation of these charts by health staff is extremely difficult.

· Bamenda Health District EPI Monitoring charts

The chart is the multiple-oblique line chart (Picture 13). It is a square divided into 12 rows and 12 columns, with the cumulative target population at the primary y-axis and the vaccination coverage rate at the secondary y-axis. It shows the vaccination coverage rate between two oblique lines. The vaccination coverage rate is read between two oblique lines. It is produced with the computer in an excel program for the synthesis of monthly EPI returns. Horizontal line charts are used in this EPI program to have the exact cumulative vaccination coverage rate (Picture 14). A horizontal bar chart is created in the EPI programme in Bamenda Health District to appreciate the monthly performance of each Health Area (Picture 15).

· Proposed monitoring charts for monitoring immunisation coverage rates

1) Multiple-oblique line chart for the monitoring of immunisation coverage rate (Picture 16)
The multiple-oblique line chart is a square with 12 rows and 12 columns at equal intervals. The principal line of the (X) abscise corresponds to the month from January to December. The monthly cumulative number of vaccinated target population since January is plotted on the vertical gridlines of this axis.

The primary ordinate (Y) is for the cumulative target population. Divide the known or estimated target population at the beginning of the year by 12 to obtain the interval between two principal lines. The first principal line is equal to the value of the interval, the second is the value of the interval multiplied by 2 for February, continue thus until the 12th principal line which should correspond to the annual target population in December.

The secondary ordinate indicates the vaccination coverage rates in percentage. Oblique lines connect the zero point of the graph to percentages on the secondary ordinate. The space between two oblique lines shows the vaccination coverage rate range in percentage. Projecting a horizontal line from the plotted point of the month to secondary ordinate gives the proportion of the annual target population vaccinated for the given month, until at the end of December when it corresponds to the vaccination coverage rate.
This multiple-oblique line chart provides only an estimate or a range of the vaccination coverage rate.

2) Simple horizontal line chart for the monitoring of vaccination coverage rate calculated from cumulative data (Picture 17).
- The abscise (X): The principal line corresponds to the end of each month from January to December. The vaccination coverage rate calculated from monthly cumulative data is plotted on the vertical gridline of the respective month of this axis.
- The primary ordinate (Y) shows the range of the vaccination coverage rate with percentages indicated against the principal gridline.
Indicate the set objective on one of the horizontal gridline of the y-axis lines that corresponds to it (bold the line). This horizontal-line chart permits the visualization of the evolution of the exact calculated vaccination coverage rates using cumulative data during the year. It facilitates the appreciation of trends of vaccination coverage rates, identification anomalies, and the taking of corrective measures monthly.

RESULTS

The analysis of charts shows that all the charts are similar to the one-oblique line chart recommended by the World Health Organisation (WHO) except those of Bamenda Health District, which is the multiple-oblique line chart. These one-oblique line charts have different presentations depending of stake holders and countries. The graph drawn on it is always ascending giving the false impression that the vaccination coverage rate is always good and increasing. The chart cannot be produced by computer in the present format. The plotting of data and interpretation of this chart by health staff is extremely difficult; they have to resort to alternative graphs to appreciate and understand the vaccination coverage rates.

The EPI Monitoring chart used in Bamenda Health District is the multiple-oblique line chart. It is a square divided into 12 rows and 12 columns, with the cumulative target population at the primary y-axis and the vaccination coverage rate expressed in percentage at the secondary y-axis. The vaccination coverage rate is read between two oblique lines. It is produced with the chart wizard of the computer; it can also be produced manually and it is easily understood by health providers in the field. Supplementary graphs are programmed and produced to enhance the appreciation of the monthly performance of each health area, and the monthly evolution of vaccination coverage rate in the course of the year.

DISCUSSION

These multitudes of one-oblique line charts used by health care providers in field create a lot of confusion and contribute to poor interpretation of vaccination coverage rate, consequently epidemics of polio and measles observed despite the input in the EPI. The increasing appearance of the graph may give a false impression that all is going on well; therefore great care should be taken in interpreting it.

The multiple-oblique line chart provides only an estimate or a range of the vaccination coverage rate. A simple horizontal-line chart for the monitoring of vaccination coverage rate calculated from cumulative data is more precise. The multiple-oblique line monitoring chart used in Bamenda Health District is a more convenient and more staff-friendly chart than the one-oblique line chart.

The horizontal-line chart permits the visualization of the evolution of the exact calculated vaccination coverage rates using cumulative data during the year. The set objective should be indicated on one of the horizontal gridline on the y-axis lines that corresponds to it (bold the line). It facilitates the appreciation of trends of exact vaccination coverage rates, identification anomalies, and the taking of corrective measures monthly.

The essence of the monitoring of the vaccination coverage rate is action oriented based on the information obtained from the interpretation of results provided by monitoring tools; the better the quality of the monitoring tool the more accurate and effective the information as shown by the supplementary graphs produced with data of monitoring charts of reference documents in this write up.

The population does not evolve in a straight line but in a spiral form and as such the vaccination coverage rate cannot start from zero at the beginning of the year. It has been observed that surveys carried out in the community at any time of the year to evaluate the vaccination coverage rate produce results that correspond to or are more compatible with vaccination coverage rates calculated from monthly cumulative data than those calculated from monthly cumulative data with the annual target population as denominator for each month.

Monitoring charts should:

Be of the same format at all levels of the health system ; Provide trends of evolution vaccination coverage rates at the end of each month using cumulative data since January of the year; Help health staff obtain information for improving and strengthening EPI activities; Assist in identifying training needs necessary to improve EPI activities; Assist supportive supervision in assessing data compiling, analysis and interpretation, vaccination coverage rates in routine EPI; Enhance the analysis and interpretation of data collected at all levels for decision making and action by health actors at all levels; Facilitate visualization of the trends of vaccination coverage rate; Be produced with computer in the same format at all levels of the health level; Be easily interpreted by health staff at all levels of health system world wide; Have a universal name and format; Show the vaccination coverage rate that would be calculated from cumulative vaccination data at end of each month of the year; Be universally and scientifically valid; Enhance feed back and dissemination of information just by using diagrams; Be easy to reproduce locally by users; Help target supervision to problem areas.

CONCLUSION
This contribution based on EPI charts for the monitoring of vaccination coverage rates has been made because of the inability of health staff to correctly fill and interpret the one-oblique line monitoring chart recommended by the WHO produced by stake holders in many formats.
It is therefore necessary that monitoring charts should be designed to produce the same vaccination coverage rates so that they can be easily visualized; otherwise health staff will resort to calculating the vaccination coverage rates, or create other tables or graphs to enable them appreciate their performance.

I highly recommend that the proposed multiple-oblique line monitoring chart and the horizontal line monitoring chart proposed by the author should be used in the field, at the Health District and Health Area, for the monitoring of vaccination coverage rates calculated from cumulative data in the Expanded Program on Immunization (EPI) to ameliorate the performance of health actors.

The author is available to provide his modest contribution to the improvement of monitoring charts for the monitoring of vaccination coverage rates in EPI.

Acknowledgement should be made to the author for the use of extracts of this document.




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REFERENCES:
.

1) Immunization Essentials, A practical field guide. USAID, ISBN 0-9742991, October 2003

2) Managing drug supply, Second edition, 1997, Management Sciences for Health & World Health Organisation.

3) Mid-Level Management (MLM) Course for EPI Managers, WHO

4) DQA reports for Cameroon, WHO

5) Immunization in Practice DIP-755; WHO/IVB/04.06

6) Expanded Programme on Immunisation (EPI) in Bamenda health district- Cameroon from 1999 – August 2005 (September 2005); Dr Mfonfu Daniel; web site: www. mfonfudaniel.blogspot.com

7) Demographic and health survey 2004, Cameroon; Vaccination coverage rate in children 12-23 months

8) Normes et Standards du Programme Elargi de Vaccination (PEV), Cameroun, Ministère de la Santé Publique, Janvier 2005.

9) Norms and Standards of Expanded Programme for Immunization (EPI), Cameroon, Ministry of Public Health, March 2002.

10) WHO EPI modules: R 1184 – 185 – 485; EPI/PHW/84/1-7

11) Déclaration de politique nationale du Programme Elargi de Vaccination (PEV), Cameroon, Juillet 2001.

12) OMS/AFRO/VPD, Juin 2002, Formation des équipes cadres de District sur la gestion du Programme Elargi de Vaccination, La Couverture Vaccinale

13) Mfonfu Daniel, Evaluation de la couverture vaccinale dans la ville de Baffoussam, Province de l’Ouest (Cameroun), Décembre 1983. Bull. OCEAC N° 60, Janvier – Février 1984.

14) Mfonfu Daniel, Surveillance Epidémiologique de la Rougeole dans le Département de la Mifi, Ouest-Cameroun, Bull. OCEAC N° 64 Juillet – Août 1984.